Stuttering Case History Form

Child's Name

1. When did you first notice your child's stuttering?*

2. Has your child's stuttering been:*

3. What makes your child's speech better?*

4. Is there a history of stuttering in the immediate or extended family?*

Please list:

5. What kind of stuttering does your child demonstrate? (check all that apply)*

Has frequent interjections (um, like, you know, well-um)
Repeats the beginnings of words (d-d-daddy, p-p-p-puppy)
Repeats whole words
Prolongs sounds (Mmmmy turn, Ssssssaturday)
Blocks or gets stuck and is not able to get sounds/words out (tension is noticed)
Revises words/phrases (starts to talk, then stop, then starts over again, sometimes changing the words)
Has unusual breathing patterns
Has unusual face or body movements (head nods, blinking, facial grimaces, leg movements)

6. Have you addressed or discussed stuttering with your child?*

7. How does your child feel about their stuttering (check all that apply)*

8. Describe your child's typical behaviors, attitudes, and play with peers:*

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Phone

This field is for validation purposes and should be left unchanged.